Intake Form | Lamp&Light

Intake

Please take a moment to fill out the form.

Personal Information:

Full Name

Date of Birth

Email address

Street Address

City, State, Country

Zip Code

Primary Phone Number

Secondary Phone Number

Check if we may leave a voicemail at your primary phone number

Occupation

Marriage and Family Information:

Name of Spouse (n/a if not applicable)

Spouse's Age

Spouse's Phone Number

Number of years married

How long did you know your spouse before getting married?

Please provide information about any previous marriages for you or your spouse:

Please list all children from current and/or previous relationships:

Spiritual/Religious Information:

Church Name (if applicable)

Pastor's Name

Number of Years at Church

Please note any recent changes in your spiritual life:

Health Information:

General Questions:

What brings you to counseling at this time?

What do you hope for from counseling?

What concerns do you have, if any, about coming to counseling?

What do you believe will have to change to see the progress you desire?

Is there any other information we should know?

Confidentiality Policy:

Contents of all counseling sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian. Lamp&Light counselors are responsible for maintaining confidentiality and ethical integrity with sensitive information and written records.

*Noted exceptions are as follow:

Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the counselor is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the counselor is required to notify legal authorities and make reasonable attempt to notify the family of the client.
Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the counselor is require to report this information to the appropriate social service and/or legal authorities.
When working with couples and groups: Lamp&Light counselors often use a collaborative, flexible, combined couple's approach. This means potentially meeting with the couple together and at times individually as appropriate and helpful throughout the process. Because the client is the couple and not the individual, there could be extenuating circumstances (i.e. adultery, relapse, etc.) where counselors retain permission to disclose pertinent information as appropriate to either spouse in situations of deception or withheld information in order to protect both spouses and maintain integrity.

I accept terms & conditions of Lamp&Light's "Confidentiality Policy"

Waiver of Liability:

In seeking biblical counseling from Lamp&Light Ministries LLC, we ask that you acknowledge your understanding of the following conditions and further release Lamp&Light Ministries LLC, its agents, affiliates, biblical counselors, employees, and all ministry team leadership from any legal liability, claim, or litigation arising from your participation in this voluntary program:

Biblical counseling will be provided by a biblical counselor from a pastoral perspective. The Lamp&Light staff is not licensed by the states where its counselors practice as professional counselors, social workers, or therapists;
All biblical counseling is provided in accordance with the biblical principles adhered to by Lamp&Light Ministries LLC and are not necessarily provided in adherence to any local or national psychological or psychiatric association;
No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the aforementioned biblical counselor(s), is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions;
It is understood by the participant client(s) that all complaints and grievances will be heard by Jacqueline vonReichbauer and Kathy Jenke. If the goal of reconciliation cannot be achieved between the aforementioned parties, then the participant client(s) will involve Peacemaker Ministries, Inc., at their expense, for the purpose of mediation or arbitration.

I accept terms & conditions of Lamp&Light's "Waiver of Liability"

Financial Policy:

The per hour fee for counseling with Jacqueline vonReichbauer or Kathy Janke is $110. Payment is due upon receipt of invoice unless exceptions are made in writing prior to services rendered.

I accept terms & conditions of Lamp&Light's "Financial Policy"

Appointment Cancellation Policy:

A 24 hour notice is required if you wish to cancel or are unable to keep an appointment. If you fail to give a 24 hour notice you agree to pay for the missed session in full at the agreed upon rate. Exceptions to this agreement can be made in written communication between client and counselor prior to the scheduled appointment only.

I accept terms & conditions of Lamp&Light's "Appointment Cancellation Policy""

Consent to Counsel:

Having read and understood the Confidentiality Policy, Waiver of Liability, Financial Policy, and Cancellation Policy I grant permission for Lamp&Light Ministries LLC to render counseling services to me.

I also understand that Lamp&Light may terminate services for noncompliance with the terms agreed upon, failure to keep appointments, violent behavior or threats of violence, or involvement in criminal behavior.

Please sign to indicate the following:

You have read the policies in this document.
You agree with and understand each of these policies.
You are enrolling yourself in counseling at your own will.

I accept terms & conditions of Lamp&Light's "Consent to Counsel"

Client Signature

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